Operational Impact of Neurology Rural Access Model: Reflections on the Importance of Demand-Shaping.

Background and Objectives: Demand for specialty neurologic care has been steadily increasing over the past several decades, and health systems are needing to meet the demands of their patients while managing a dwindling workforce. This retrospective study investigates the operational impact of a regional neurology clinic staffed by advanced practice providers with remote physician oversight in a "hub and spoke" delivery model to serve lower complexity patients. Methods: A retrospective, cross-sectional study was conducted to evaluate outcomes. Descriptive analysis of referral volumes, cancellation/no-show rates, and patient complexity as determined by the reason for referral were used to evaluate patients who received referrals from rural counties north of the primary neurology practice before and after the opening of the regional clinic. These metrics were evaluated longitudinally from counties of interest and for differences in patients seen at the regional clinic vs primary neurology practice. Results: Referral volumes from the northern counties increased at significantly higher rates after the opening of the regional clinic than other counties in the serviced area. This resulted in an increase in patients seen in the hub clinics and spoke clinic. The regional clinic did see patients who were less complex than the primary practice; however, the total volume of low-complexity patients scheduled at the primary practice did not decrease. Cancellation and no-show rates did not seem to be affected in either clinic. Discussion: The opening of a regional "spoke" clinic resulted in the generation of greater referral volumes that exceeded the capacity created by the clinic. Owing to this, there was an increase in the number of patients seen from the regional counties in the hub clinics, negating the potential benefit of improving access for high-complexity patients. Importance of demand-shaping and appropriate utilization as part of the value equation are discussed, followed by discussion of mitigation strategies.

Implementation of E-Consults in an Integrated Health System for a Value Population.

The adoption of e-consults, a form of formal, asynchronous provider-to-provider communication in which specialty medical advice is sought, has been proven to reduce unnecessary specialty consultations, build provider relationships, and reduce fragmentation of care. While the utilization of e-consults is generally a well-accepted alternative method of incorporating specialist expertise into a patient's plan of care and adoption has become common, the implementation of this disruptive care delivery modality can be challenging. This article seeks to describe the process and operational outcomes of e-consult adoption in an integrated health system with a focus on the benefits in the context of value-based care. Implications of e-consult adoption on referral volumes, wait times, and cancellation rates at the service line level are investigated. E-consult adoption and completion metrics, including utilization, completed versus rejected, turn-around times, and projected cost savings, are also discussed.